_Well Construction - GW1_20230315 (21)

WELL CONSMUCTION^RECORD For IntcrualUse ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bill`,Kenned�l 14,WATER2l)NES
Y Y FROM TO DESCRIPTION
Well Contractor Name fL
&.
2834-A 3 . s 0 ft.
NC Well Contractor Certification Number -.15:OUTER`CASING formn ,ea` ells OR L1NER' a" livable ,
FROM TO .: DIAMErER THICKNESS MATERIAL
'Kennedy Well Drilling 0 ft• .11 fL 16.25 ]n 1 SDR-21 I PVC
Company Name <:16_1 NNER:CASING.OR•TUBING. 'eotherioaI closed-loo
FROM TO DIAMETER
WIV TffiCENESS MATERIAL
2.Well Construction Permit#: OD I-X ft. ft in
List all applicable well permits(i.e.County.State,Variance,Injection,etc.) it in.
3.Well Use(check well use): 17=scREEIv_ -
Water Supply Well: . - -FROM I TO: I DIAMETER:.,.SLOT S1 I-THICKNESS -MATERIAL
❑Agricultural ❑MunicipaUPublic ft It_ in.
[]Geothermal(Heating/Cooling Supply) 995M�sidential Water Supply(single) R IL in.
❑Industrial/Commercial DResidential Water Supply(shared) 18:GROUT,
FROST TO MATERIAL EMPLACEMENT METHOD&AMOUNT
dIrri ation 0 ft 20+ ft- . .Bentonite Hydrate chips in place
Non-Water Supply Well:
ft ft
❑Monitoring ❑Recovery
Injection Well: ft. %
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRiiVEL PACK if a livable .
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EAD LACE11fENT METHOD
rt. fa
❑Aquifer Test ❑Stormwater Drainage
ft rL
❑Experimental Technology ❑Subsidence Control
20 DRILLING`LOG:attach additional slieets'if neeessa
❑Geothermal(Closed Loop) ❑Tracer FROM: TO DESCRIPTION rnlor hardn soillrock - etc,
❑Geothermal(Heating/Cooling Return ❑Other ex lain under#21 Remarks), ft 3 ft
4.Date Well(s)Completed: -off 23 Well ID# ?u .. ft
gue
ft. rr:
5a.Well Location: & it Imo, t
6arrvr�
r ft ft.
Facility/04erNamc Facility lD#(if applicable) ft ft- i R I r_n 2 l
Physical Address,City,and Zip :21]2ER4ARRICS ': 7777777
County Parcel IdentificationNo.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds.oir decimal degrees: 22.Certification:
(ifwell field,one lattlong is sufficient)
15-%'4f t-q N W .
SignaturdalCeftified Well ContracVr Date
6.Is(are)the well(s): Arerinainent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A.NCAC 02C:0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or C<10 copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under-921 remarks.section or on,the back of this form. 23.Site diagram or;additloiial well details:
You may use:the back of this page to provide additional well site details or well
8.Plumber of wells constructed: construction details..You may also attach additional pages if necessary.
For multiple injection or nan-water supply wells ONLY with the same construction,you can.
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft) 24a• For All.Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and�22@100� construction.to the fallowing:
10.Static water level below top of casing: -7 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use.-+- 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
rota 24a above,also submit a copy of this form within 30 days of completion of well
12,Well construction method: rotary construction.to the following:
(i.e.auger,rotary,cable,direct push;etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air 24c.For Water Supply&Injection.Wells:
Also submit one copy, of this form within 30 days,of completion of
granular hypocholyde well'construction to the county health department of the county where
13b.Disinfection type: Amount:
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013